Robotic Kidney Transplantation Consent

Informed Consent For Surgical Operation / Procedure

Procedure: Robotic Kidney Transplantation

1. Patient Identification

I, ______________________________ (patient/next of kin/legal guardian), aged ____ years, in my full senses, voluntarily authorize and give my complete consent for performance of the following procedure(s)/operation(s)/treatment(s):

Procedure: _______________________________
Diagnosis: ________________________________
Major illness & comorbidities: ________________________________

2. Authorization for Procedure

I authorize Dr. __________________ to perform the above procedure, along with such assistants and associates as may be selected by him/her.

I understand that members of the surgical team, including residents or trainees under appropriate supervision, may perform parts of the procedure according to their training and competence.

3. Nature of Procedure

Robotic kidney transplantation is a minimally invasive procedure in which a healthy donor kidney is implanted using a robot-assisted surgical approach.

The donor kidney is usually placed in the lower abdomen/pelvis and connected to the recipient’s blood vessels and urinary bladder.

A temporary DJ/ureteral stent is usually placed.

4. Benefits and Indications

The intended benefits include:

  • Definitive treatment for end-stage kidney disease.
  • Improved survival and quality of life compared with long-term dialysis.
  • Better cosmetic outcome with a minimally invasive approach.
  • Potentially faster recovery.
  • Possible reduction in wound complications in selected patients.

I understand that no guarantee can be given regarding:

  • Immediate graft function.
  • Long-term graft survival.
  • Freedom from rejection or infection.
  • Freedom from dialysis.
  • Overall transplant success.

Although the planned procedure is robotic, conversion to open kidney transplantation or modification of the surgical procedure may be required depending on intraoperative findings or safety concerns.

5. Risks and Complications

  • Intra-operative
    • Bleeding: 5–15%
    • Blood transfusion: 5–10%
    • Major vascular complications such as thrombosis, kinking or vessel injury: 2–8%
    • Injury to bladder, bowel, ureter, iliac vessels, nerves or abdominal-wall structures: 1–5%
    • Warm-ischaemia/rewarming-related graft injury.
    • Difficulty with graft placement or vascular anastomosis due to obesity, adhesions or anatomy.
    • Conversion to open surgery: 2–10%
    • Anaesthesia-related complications: <1–2%
    • DVT/PE: 1–3%
    • ICU care: 5–15%
    • Rare risk of death: <1–2%
  • Post-operative
    • Pain at incision/port sites.
    • Wound/surgical-site infection: 2–8%
    • Urinary leak from ureteric implantation site: 2–10%
    • Ureteric stricture/obstruction: 2–8%
    • Haematuria. Lymphocele/fluid collection: 5–15%
    • Bleeding/haematoma: 2–10%
    • Delayed graft function/temporary dialysis: 5–20%
    • Graft vascular thrombosis: 1–5%
    • Re-exploration/reoperation: 5–15%
    • Bowel complications/ileus: 2–10%
    • Chest complications: 2–8%
    • Incisional/port-site hernia: 1–5%
    • Readmission after discharge.
  • 10. Transplant-Specific Risks
    • The transplanted kidney may not function immediately.
    • The graft may function poorly or fail despite successful surgery.
    • Acute or chronic rejection may occur.
    • Rejection may require hospitalisation, biopsy, additional medication or further treatment.
    • Temporary or permanent dialysis may be required.
    • Blood transfusion, kidney biopsy, radiological procedures or additional surgery may be required.
    • If the graft fails, I may require dialysis and, in some cases, graft nephrectomy.

6. Postoperative Course

I understand that:

  • A urinary catheter may be required.
  • Surgical drains may be placed.
  • A DJ stent may be inserted and will require later removal.
  • Intravenous lines and central venous/arterial monitoring may be required.
  • Regular follow-up, blood tests and imaging are necessary.
  • Strict adherence to immunosuppressive medicines is essential.
  • The transplant may be postponed or cancelled if unexpected donor, recipient, surgical or medical problems arise.
  • Histopathology or biopsy may be required when clinically indicated.

I understand that lifelong immunosuppressive medication will be required after transplantation.

Long-term immunosuppression carries risks including:

  • Infection.
  • Diabetes.
  • High blood pressure.
  • Weight gain.
  • Bone disease.
  • Liver or blood-related side effects.
  • Increased long-term malignancy risk.

7. Alternatives to Procedure

I have been informed of alternatives including:

  • Continued haemodialysis.
  • Peritoneal dialysis.
  • Open kidney transplantation.
  • Conservative/supportive treatment.
  • Deceased-donor or alternate-donor transplantation depending on availability.

8. Anaesthesia and Pain Management

I understand the risks associated with local, regional, or general anaesthesia.

Pain management options have been explained.

9. Photography / Data Use

I consent to:

☐ Medical photography/video for academic purposes

☐ Use of anonymized clinical data

10. Intraoperative Decision Consent

I authorize the surgeon to perform additional procedures considered necessary if unexpected findings arise during surgery.

11. Team-Based Care

I understand that supervised residents, fellows, or assistants may participate.

12. Patient Statement

I confirm that:

  • The nature of surgery has been explained.
  • Risks, benefits, and alternatives have been explained.
  • My questions have been answered satisfactorily.
  • I voluntarily consent.

Patient to write in own handwriting:

“I have understood the procedure, risks, benefits and alternatives explained to me in a language I understand.”

Signatures

Patient Name & Signature: ______________________________________

Date: ____________________ Time: ____________________

Doctor Name & Signature: ______________________________________

Date: ____________________ Time: ____________________

Witness Name & Signature: ____________________________________

Contact No.: ______________________________

ATTENDANT CONSENT (If applicable)

Reason patient unable to consent:

Attendant Name: __________________________________________

Relationship: _____________________________________________

Signature: ________________________________________________

Contact No.: ______________________________________________

INTERPRETER STATEMENT (If applicable)

I confirm an accurate explanation in understandable language.

Name: _________________________________________________

Signature: ______________________________________________

Contact: ________________________________________________

HIGH-RISK CONSENT (If applicable)

High-risk factors explained due to:

Patient Signature: ________________________________________

Doctor Signature: _________________________________________

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